Download Standards for Accreditation of Dental Sleep Medicine Facilities

Standards for Accreditation of Dental Sleep Medicine Facilities
AADSM Accreditation Standards Table of Contents
General Standards
A-1
Address (MANDATORY)
p. 4
A-2
Facility License (MANDATORY)
p. 4
A-3
ADA Code of Ethics (MANDATORY)
p. 4
A-4
Dental Sleep Medicine Activity (MANDATORY)
p. 4
Personnel
B-1
Dental Director (MANDATORY)
p. 5
B-2
Dental Director Qualifications (MANDATORY)
p. 5
B-3
Dental Director Responsibilities (MANDATORY)
p. 6
B-4
Dental Director Continuing Education (MANDATORY)
p. 6
B-5
Dental Sleep Medicine Clinical Auxiliaries
p. 7
B-6
Dental Sleep Medicine Clinical Auxiliaries Continuing Education
p. 7
B-7
Dental Sleep Medicine Clinical Auxiliaries Additional
Certification
Coding and Billing Personnel Training
p. 7
B-9
Dental Sleep Medicine Administrative Staff Continuing
Education
Patient Acceptance and Records Policies
p. 8
C-1
Patient Acceptance
p. 8
C-2
Patient Records Maintenance
p. 8
C-3
Patient Records: Documentation From the Referring Physician
p. 9
C-4
Oral Appliance Therapy
p. 9
C-5
Combination Oral Appliance – Positive Airway Pressure
p. 9
B-8
p. 7
Facility
D-1
Use of Space
p. 10
D-2
Dental Sleep Medicine Facility Availability
p. 10
D-3
Treatment and Consultation Rooms – Physical Characteristics
p. 10
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Standards for Accreditation of Dental Sleep Medicine Facilities
D-4
Satellite Clinical Locations
p. 10
Oral Appliances
E-1
Appropriate Oral Appliances (MANDATORY)
p. 11
E-2
Materials for Oral Appliances
p. 11
Policies and Procedures
F-1
Policy and Procedures Manual
p. 11
F-2
Protocols: Treatment with and Titration of Oral Appliances
p. 12
F-3
Fraud, Waste and Abuse Policies (MANDATORY)
p. 12
F-4
HCPCS/ICD-10 Codes Update
p. 12
Oral Appliance Safety Procedures
G-1
Oral Appliance Safety Program
p. 12
G-2
Incident Investigation
p. 12
G-3
Oral Appliance Failure, Repair and Maintenance Plan
p. 13
Consumer Services
H-1
Oversight (MANDATORY)
p. 13
H-2
Patient Rights
p. 13
H-3
Plan of Care/Informed Consent
p. 13
H-4
Receipt of Oral Appliances
p. 13
H-5
Verification of Training
p. 14
H-6
Patient Complaints
p. 14
Emergency Procedures
I-1
Emergency Plan
p. 14
I-2
Emergency Equipment
p. 15
Follow-up
J-1
Follow-up Care
p. 15
J-2
Post-Delivery Follow-up
p. 15
J-3
Short-Term Follow-up
p. 15
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Standards for Accreditation of Dental Sleep Medicine Facilities
J-4
Long-Term Adherence with Oral Appliance Therapy
p. 15
Claims Submission Audit
K-1
Patient Records Audit
p. 16
K-2
Billing Discrepancies Procedure
p. 16
Quality Assurance
L-1
Quality Assurance Program and Reporting
p. 16
Disclosure of Persons Having Ownership, Financial or Control Interest
M-1
Disclosure (MANDATORY)
p. 17
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Standards for Accreditation of Dental Sleep Medicine Facilities
General Standards
Standard
A-1 – Address (MANDATORY)
American Academy of Dental Sleep Medicine (AADSM) accredited dental sleep
medicine (DSM) facilities must have a permanent, physical address recognized by
the United States Postal Service. The DSM facility address may include a P.O. Box for
mailing purposes only.
A-2 – Facility License (MANDATORY)
AADSM accredited DSM facilities must maintain a valid license, certificate of
occupancy, and/or permit, when required by applicable law and regulation, to
provide health care services and/or durable medical equipment (DME). It is the
responsibility of the DSM facility to maintain compliance with all licensing acts, local
building codes and any other laws relevant to the facility’s operation.
Failure to comply with the stipulations in this paragraph is sufficient for denial
and/or revocation of accreditation. A DSM facility’s valid healthcare license,
certificate of occupancy or business permit fulfills this standard. Where additional
licenses or permits are required for providers of DME, evidence of such is required
to fulfill this standard. If applicable law does not require a dental sleep medicine
facility to have a healthcare license, certificate of occupancy or business permit, or
DME license or permit, written attestation of such by the dental director of the
facility is required.
A-3 – ADA Code of Ethics (MANDATORY)
AADSM accredited sleep medicine facilities are required to follow the American
Dental Association Principles of Ethics and Code of Professional Conduct. The DSM
facility must either have a hard copy on hand or have the ability to access easily an
updated copy of the American Dental Association Principles of Ethics and Code of
Professional Conduct electronically.
A-4 – Dental Sleep Medicine Activity (MANDATORY)
The dental director must have been providing DSM services within this dental sleep
medicine facility for a minimum of one year prior to submitting an accreditation
application. DSM services must include a minimum of 12 appliance insertions, as
well as documentation of post-delivery follow-up and short-term follow-up for
each. Documentation of long-term follow-up is required for a minimum of 5 of these
cases.
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Standards for Accreditation of Dental Sleep Medicine Facilities
B. Personnel
Standards B-1 through B-4 relate to the appointment, responsibilities and
continuing education of a dental director.
Standard
B-1 – Dental Director (MANDATORY)
a) AADSM accredited DSM facilities must designate a single professional dentist
as dental director. The dental director must have a license valid in the state
of the facility and in all states in which patients are seen.
b) An individual can serve as dental director of up to three (3) DSM facilities,
including satellite locations, regardless of their accreditation status.
B-2 – Dental Director Qualifications (MANDATORY)
The dental director must be either
1. A qualified dentist who is a Diplomate of the American Board of Dental Sleep
Medicine (ABDSM)
OR
2. A qualified dentist who:
a. has completed a required 30 credits of continuing education within the
past three years. A minimum of 20 credits must be in dental sleep
medicine. The additional credits must be sleep medicine related. After
January 1, 2017, dental directors must complete, within the past two
years, a minimum of 25 hours of recognized continuing education in
dental sleep medicine (e.g., American Dental Association Continuing
Education Recognition Program [ADA CERP] or Academy of General
Dentistry Program Approval for Continuing Education [AGD PACE])
provided by a dental sleep medicine focused non-profit organization or
accredited dental school; and
b. has delivered a minimum of twelve appliances within the previous 12
months.
c. To retain the accreditation, the dental director must obtain ABDSM
certification within 2 board certification cycles. The dental director must
provide a copy of the official notification from the ABDSM attesting to
successful completion of all requirements including but not limited to the
board examination.
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Standards for Accreditation of Dental Sleep Medicine Facilities
B-3 – Dental Director Responsibilities (MANDATORY)
The dental director:
a. is responsible for the direct or indirect and ongoing oversight of patient
evaluation, treatment, and follow-up care;
b. is responsible for proper handling, storage, maintenance, and ongoing
assessment of oral appliances;
c. is responsible for the qualifications of all dentists and auxiliary personnel,
d. must provide direct and ongoing oversight of the evaluation and testing
protocols, as permitted under local laws and regulations;
e. must review, report, and modify as necessary the facility’s quality assurance
program on a quarterly basis; and
f. must be present in the dental sleep medicine facility on a regular basis and
not less than 40 hours each month.
B-4 – Dental Director Continuing Education (MANDATORY)
The dental director must participate in at least 10 credits per year averaged over
three years of continuing education. A minimum of 5 credits per year must be ADA
CERP recognized or AGD PACE approved credit in dental sleep medicine. The
additional five credits may be sleep medicine related AMA PRA Category 1 CME.
After January 1, 2017, dental directors must complete, within the past two years, a
minimum of 25 hours of recognized continuing education in dental sleep medicine
(e.g., American Dental Association Continuing Education Recognition Program [ADA
CERP] or Academy of General Dentistry Program Approval for Continuing Education
[AGD PACE]) provided by a dental sleep medicine focused non-profit organization
or accredited dental school. Compliance with CE requirements is required for all
dental directors, regardless of whether they are certified by the ABDSM.
Compliance with this standard must be documented.
Standards B-5 through B-7 address requirements for DSM clinical auxiliaries,
which may include dental assistants, dental hygienists, nurses, and other
auxiliary personnel as allowed under state law. Each must be licensed where
required by state law. These standards do not differentiate between the
various job descriptions or titles that dental sleep medicine facilities may use
for the employment of various clinical auxiliaries. CPR certification is
required for all clinical staff members, regardless of their duties or titles.
These requirements are in addition to any state or local requirements.
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Standards for Accreditation of Dental Sleep Medicine Facilities
B-5 – Dental Sleep Medicine Clinical Auxiliaries
Clinical auxiliary staffing at dental sleep medicine facilities must be adequate to
address the workload of the dental sleep medicine facility and assure the safety of
patients. If the dental sleep medicine facility employs clinical auxiliary staff, they
must be appropriately trained, supervised, and, where required by state law,
licensed.
B-6 – Dental Sleep Medicine Clinical Auxiliaries Continuing Education
The dental sleep medicine facility’s clinical auxiliary staff must each participate in an
average of 5 hours per year of ADA CERP recognized credit, AGD PACE approved
credit, or sleep-related in-service educational activities over a three year period.
Education sessions conducted at the facility are acceptable for fulfilling this
standard provided the session has defined educational objective(s) and attendance
is documented by a roster signed by the dental sleep medicine facility’s dental
director. Documentation of continuing education must be maintained for each
clinical auxiliary staff member.
B-7 – Dental Sleep Medicine Clinical Auxiliaries Additional Certification
Each dental sleep medicine clinical auxiliary must have valid American Heart
Association or American Red Cross certification, or its equivalent, in
cardiopulmonary resuscitation. For the purpose of AADSM Accreditation
requirements, the level of CPR training must be suitable for healthcare
professionals. Valid certification in cardiopulmonary resuscitation includes skills
training.
Standard B-8 relates to the training of all staff that performs coding and billing
of services.
B-8 – Coding and Billing Personnel Training
A minimum of 5 hours of initial training must be provided for new staff responsible
for coding and billing of services provided by the DSM facility. Some suggested
areas of training include:
a. Coding requirements related to the services provided.
b. Claim development and submission processes.
c. Documentation of services rendered.
d. Billing standards and procedures, including review of rejected claims.
e. Reason(s) for claim rejection.
f. Legal sanctions for submitting deliberately false or reckless billings.
Documentation of training must be maintained for each coding and billing staff
member. Training materials, attendance sheets and course outlines must be
maintained for training offered at the facility. Certificates or letters of completion
should be maintained for courses attended outside the DSM facility.
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Standards for Accreditation of Dental Sleep Medicine Facilities
Standard B-9 – Dental Sleep Medicine Administrative Staff Continuing
Education
New staff responsible for dental sleep medicine administrative responsibilities must
each participate in 2 hours of initial training through either an ADA CERP
recognized or AGD PACE approved provider. Education sessions conducted at the
facility are acceptable for fulfilling this standard provided the session has defined
educational objectives and attendance is documented by a roster signed by the
dental sleep medicine facility’s dental director. Documentation of continuing
education must be maintained for each new administrative staff member.
C. Patient Acceptance and Records Policies
Standard
C-1 – Patient Acceptance
The DSM facility’s Policy and Procedures Manual must address patient acceptance
policies. Written policies for patient acceptance must include:
a. a mechanism for acceptance;
b. criteria for exclusion; and
c. information required from a physician prior to treatment.
The AADSM recognizes that concern for patient safety, clinical judgment, or other
appropriate reasons may limit a dental sleep medicine facility from accepting all
patients.
C-2 – Patient Records Maintenance
The DSM facility must maintain accurate, pertinent, accessible, confidential and
secure patient records for all patients evaluated and/or treated there. Records must
be maintained in written or electronic format, in accordance with privacy and
security standards of the Health Insurance Portability and Accountability Act
(HIPAA) and other applicable state standards. These records must provide
documentation of all patient interactions including initial evaluation, diagnosis,
treatment, testing, follow-up and miscellaneous encounters including phone calls
and letters related to treatment.
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Standards for Accreditation of Dental Sleep Medicine Facilities
C-3 – Patient Records: Documentation from the Referring Physician
The DSM facility must receive an order from the referring physician documenting
medical necessity of the oral appliance. The order must be maintained in the patient
record.
Prior to initiating treatment, all patient medical charts must include: physician
prescription, prior overnight sleep study results, patient questionnaires, patient
history, clinical examination, and documentation of informed consent.
C-4 – Oral Appliance Therapy
Patients receiving an oral appliance for treatment of sleep-related breathing
disorders must receive all of the following, and each must be documented in the
medical record:
1. Review of sleep-related breathing disorders and potential consequences if
left untreated.
2. Review of treatment alternatives for sleep-related breathing disorders.
3. Benefit of treatment recommendations.
4. Potential risks and complications related to treatment recommendations.
5. Oral appliance care and use instructions.
6. Follow-up care per the AASM Practice Parameters and AADSM Treatment
Protocols.
C-5 – Combination Oral Appliance – Positive Airway Pressure
Patients prescribed positive airway pressure (PAP) treatment in combination with
oral appliance therapy must be managed in coordination with a treating physician.
The patient’s dental sleep medicine record must include documentation of physician
management of the PAP component as well as appropriate documentation of the
oral appliance therapy.
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Standards for Accreditation of Dental Sleep Medicine Facilities
D. Facility
Standard
D-1 – Use of Space
Accreditation is granted to a single DSM facility, generally defined by a physical
space used for conducting services related to dental sleep medicine. All of the
elements required to provide evaluation, treatment, and follow-up care related to
dental sleep medicine are contained within the defined space. Up to 2 additional
satellite clinical locations are permitted under the primary accreditation application
as long as the Dental Director remains the same, and all criteria listed under D-4 are
also met. The administrative office(s) of the DSM facility may be separate from the
clinical site. In such circumstances, the administrative office(s) must also meet the
AADSM Standards for Accreditation, as they function as a part of the broader DSM
program.
D-2 – Dental Sleep Medicine Facility Availability
The DSM facility must:
a. Maintain a publicly listed telephone number. Exclusive use of a pager, mobile
phone, or answering machine will not serve to meet this standard.
b. Maintain posted hours of operation.
If the DSM facility chooses to distribute patient education materials and advertising,
this information must display the facility contact information including address and
phone number.
D-3 – Treatment and Consultation Rooms – Physical Characteristics
All treatment rooms must be hygienic. They must be suitably equipped to provide
good light and oral access for a thorough intraoral and extraoral evaluation. Patient
consultations must be provided in a private environment.
D-4 - Satellite Clinical Locations
DSM satellite clinical facilities may cumulatively provide no more than 20% of the
total monthly available DSM patient care hours (for primary and satellite facilities
combined) and must operate under the same federal tax ID number as the main
dental sleep medicine facility. The Dental Director must be physically present
within each DSM satellite clinical facility during dental sleep medicine patient care
hours for a minimum of 25% of each satellite facility’s available patient care hours.
Each DSM satellite clinical facility must meet all other accreditation requirements.
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Standards for Accreditation of Dental Sleep Medicine Facilities
E. Oral Appliances
Standard
E-1 – Appropriate Oral Appliances (MANDATORY)
The DSM facility must provide appropriate, 510K FDA cleared, quality oral
appliances (orthotics) to patients. Appliances are utilized to reposition the tongue,
mandible and/or other pharyngeal tissues in an effort to create and maintain a
patient’s airway during sleep. For this accreditation, such appliances may include
any of the devices listed below:
a. Tongue-retaining devices – devices used to treat sleep-disordered breathing
using a vacuum bulb or other mechanism to maintain the tongue in a more
anterior position.
b. Mandibular advancement devices – oral appliances used to treat sleepdisordered breathing that reposition the mandible in a forward position.
E-2 – Materials for Oral Appliances
The DSM facility must have the available manufacturer features, warranties and
instructions for the oral appliance(s) that it provides, including documentation of
FDA clearance.
F. Policies and Procedures
Standard
F-1 – Policy and Procedures Manual
The DSM facility must implement and maintain a policy and procedures manual that
is easily accessible to all applicable staff members, in written or electronic format.
The manual must:
1. Contain all policies, procedures and protocols specific to the DSM facility.
2. Include names and job descriptions for all DSM facility personnel.
3. Delineate education, training, responsibilities, certifications and licensures.
4. Document continuing education requirements related to the specialized
equipment it provides to patients.
5. Include evidence of annual review of the manual, with periodic updates by
the dental director as warranted.
6. Support compliance with all State and Federal regulations, as it pertains to
the business, including but not limited to, Stark Laws and the Health
Insurance Portability and Accountability Act (HIPAA), and all Medicare
requirements.
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Standards for Accreditation of Dental Sleep Medicine Facilities
Policies should indicate that the DSM facility follows all current AASM Practice
Parameters and Clinical Guidelines and all current AADSM Treatment Protocols.
F-2 – Protocols: Treatment with and Titration of Oral Appliances
The dental sleep medicine facility must maintain written, paper or electronic format
protocols for treatment of sleep related breathing disorders with oral appliance
therapy and protocols for oral appliance titration.
F-3 – Fraud, Waste and Abuse Policies (MANDATORY)
The DSM facility must implement policies to prevent and control fraud, waste and
abuse by using standards of conduct which ensure the organization’s compliance
with applicable Federal, State, local laws and regulations. These standards must be
available for review in either written or electronic format.
F-4 – HCPCS/ICD-10 Codes Update
The dental sleep medicine facility must have guidelines in place to ensure that the
most current HCPCS/ICD-10 codes are utilized in billing the services provided.
G. Oral Appliance Safety Procedures
Standard
G-1 – Oral Appliance Safety Program
The DSM facility must have a policy, in written or electronic format, which promotes
the safe use of oral appliances and minimizes safety risks, infections and hazards
both for its staff dispensing appliances and for its patients receiving the oral
appliance for use.
G-2 – Adverse Event Investigation
The DSM facility must investigate adverse events that result in acute injuries,
accidents or hospitalization in which the dental sleep medicine facility may have
contributed to the event.
a. The number of adverse events, event outcomes and resolutions must be
maintained in a written log or electronic database.
b. The investigation must be initiated as soon as possible and within two
business days after the dental sleep medicine facility becomes aware of any
adverse event.
c. The investigation must include documentation of all necessary information,
pertinent conclusions, and whether changes in the system(s) or processes
are needed.
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Standards for Accreditation of Dental Sleep Medicine Facilities
d. The dental sleep medicine facility must provide subsequent written followup to the adverse event to prevent future occurrences.
G-3 – Oral Appliance Failure, Repair and Maintenance Plan
The DSM facility must have, in written or electronic format, a policy for identifying,
monitoring and reporting (where indicated) failure, repair and preventive
maintenance of oral appliances provided to the patient.
H. Consumer Services
Standard
H-1 – Oversight (MANDATORY)
A qualified dentist member of the DSM facility staff must provide a face-to-face
meeting prior to the fitting of an appliance.
A qualified dentist member of the DSM facility staff must physically be present in the
DSM facility at all times while patients are being seen.
This standard can be met by either the dental director or additional qualified dentist
staff.
H-2 – Patient Rights
Patient rights must be protected during all interactions with the DSM facility. The
patient has the right to considerate and respectful service without regard to race,
creed, national origin, sex, age, disability, diagnosis, or religious affiliation. DSM
facility staff must provide patients and prospective patients with sufficient
information to base a decision regarding facility selection.
H-3 – Plan of Care/Informed Consent
The DSM facility must provide the patient with a written plan of care following the
initial evaluation and prior to fabricating an oral appliance for treatment of sleep
related breathing disorders. The patient must also give informed consent before
initiating oral appliance therapy.
H-4 – Receipt of Oral Appliances
The DSM facility must:
a. Provide information to the patient regarding expected delivery time for
receipt of the prescribed oral appliance.
b. Document that the appliance was personally checked by the treating dentist
for structural integrity.
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Standards for Accreditation of Dental Sleep Medicine Facilities
c. Provide a written warranty for the appliance that delineates what support is
included in the appliance fee and what services are likely to be needed at
additional cost.
d. Verify and document in the patient’s chart the patient’s receipt of the
appliance.
e. Provide daytime and after-hours contact information to each patient at the
time of delivery of the prescribed appliance.
H-5 – Verification of Training
The DSM facility must, as applicable:
a. Provide, or coordinate the provision of, appropriate information related to
the set-up, features, routine use, troubleshooting and maintenance of the
appliance provided to the patient.
b. Supply to the patient and/or caregiver(s) clear, written or pictorial, oral or
electronic instructions related to the use, maintenance, infection control
practices for, and potential hazards of, the oral appliance as appropriate.
H-6– Patient Complaints
a. Within five calendar days of receiving a patient’s written complaint, the DSM
facility must notify the patient that it has received the complaint and has
initiated an investigation of the incident.
b. Within fourteen calendar days, the DSM facility must provide written
notification to the patient of the result of the investigation and maintain such
notification in the patient’s chart.
c. The DSM facility must maintain documentation of all complaints received,
findings from prior and current investigations and complaint resolutions.
d. Based upon the results of each investigation, there must be evidence that
procedures have been developed to correct the problem identified in order
to prevent future occurrences.
I. Emergency Procedures
Standard
I-1 – Emergency Plan
AADSM accredited DSM facilities must have a written emergency plan accessible in
paper or electronic format that delineates the following:
a. mechanisms and specific details for contacting emergency personnel;
b. the dental sleep medicine facility personnel to be contacted in an emergency;
c. personnel and procedures for responding to after work hours questions and
technical problems encountered by patients; and
d. outline the specific responsibilities of the clinical staff.
At a minimum, emergency policies must include procedures for the following:
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Standards for Accreditation of Dental Sleep Medicine Facilities
a. Medical emergencies.
b. Environmental emergencies such as fire, weather, belligerent patients, and
bomb threats.
I-2 – Emergency Equipment
The DSM facility must have accessible all appropriate emergency equipment to
address all possible emergencies outlined in their emergency plan.
J. Follow-up
Standard
J-1 – Follow-up Care
The DSM facility must provide appropriate follow-up services to the patient and/or
caregiver(s) consistent with the type(s) of oral appliance and/or service(s)
provided.
J-2 – Post Delivery Follow-up
A member of the dental sleep medicine facility staff must place a phone call, send an
email, or otherwise attempt to directly contact the patient 1-3 days after delivering
a new oral appliance. The patient is given the opportunity to review instructions,
express concerns, and provide feedback. This contact is documented in the patient
chart.
J-3 – Short-term Follow-up
The DSM facility must offer face-to-face follow-up to patients who are prescribed
oral appliance therapy to ensure adherence, address patient concerns, assess
appliance fit, and check for complications within four weeks of initiating therapy.
Additional follow-up visits must be provided every 1-12 weeks until the oral
appliance home titration phase is successfully completed, the oral appliance has
reached its maximum limit of mandibular advancement, or the patient has reached
his/her tolerable limit of mandibular advancement. Documentation of short-term
follow-up is to be documented in the patient chart.
J-4 – Long-term Adherence with Oral Appliance Therapy
The DSM facility must encourage long-term follow-up to patients who are
prescribed oral appliance therapy. The facility must maintain a follow-up protocol
which includes a face-to-face patient evaluation at six months after successful
titration and at least annually thereafter.
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Standards for Accreditation of Dental Sleep Medicine Facilities
The annual recall exam must evaluate efficacy, patient adherence, side effects,
symptoms as well as the structural integrity of the oral appliance and the need for
possible additional titration.
Long-term follow-up must be documented in the patient record. Progress notes and
follow-up reports, as well as other pertinent information, must be shared with the
patient’s physician and appropriate healthcare providers on a regular basis.
The DSM facility should document notification of the treating physician whenever
its staff or dentist(s) become aware that any patient has discontinued oral appliance
therapy for a sleep related breathing disorder.
K. Claims Submission Audit
Standard
K-1 – Patient Records Audit
A minimum of five patient records must be self-audited at least annually by the DSM
facility. The audit must demonstrate:
a. Accurately coded bills for oral appliances documented in the patient chart.
b. Reasonable and medically necessary oral appliances have been provided to
the patient.
The DSM facility must maintain documentation of annual audits for the duration of
the accreditation period.
K-2 – Billing Discrepancies Procedure
The DSM facility must have a procedure for identifying and correcting billing
discrepancies. This procedure must include:
1. Designation of staff member(s) or billing company responsible for handling
coding and billing.
2. The use of audits and/or other risk evaluation techniques to monitor billing
activities.
3. Procedures to resolve and prevent recurrence of identified billing
discrepancies.
L. Quality Assurance
Standard
L-1 – Quality Assurance Program and Reporting
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Standards for Accreditation of Dental Sleep Medicine Facilities
The Dental Sleep Medicine (DSM) facility must implement a quality assurance
program that measures patient satisfaction, oral appliance adherence and billing
practices.
1. The DSM facility must track patient satisfaction in relation to access to care,
delivery of appliance, and service. A patient survey must be completed by a
minimum of 80% of the patients treated.
2. The DSM facility must track patient adherence for oral appliance use. The
DSM facility must have a system in place to track patient adherence and
follow up care.
3. The DSM facility must track frequency of billing and coding errors (e.g.
number of insurance claims denied, errors resulting in claims denial).
All three quality assurance indicators must be reported and reviewed at least once
per quarter. The quality assurance report must be reviewed and signed by the DSM
facility dental director quarterly.
M. Disclosure of Persons Having Ownership, Financial or Control Interest
Standard
M-1 – Disclosure (MANDATORY)
The DSM facility must provide current information to the accrediting body for all
individuals and joint venture companies holding an ownership or controlling
interest (5% or more). The DSM facility must report to the accrediting body any
agent relationship and managing employee interest in the DSM facility, and
subcontractor relationships with another DSM facility.
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